A list of the most recent deficiencies for St James Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-10-04 | 2023-10-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-04 | 2023-10-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-04 | 2023-10-27 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-10-04 | 2023-10-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-10-11 | 2023-10-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-08 | 2023-07-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-08 | 2023-07-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-08 | 2023-07-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-08 | 2023-07-03 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-06-08 | 2023-07-03 | Y |
| Provide specialized rehabilitative services by qualified personnel, when ordered for a resident by a doctor. | Health | 2023-06-08 | 2023-07-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-29 | 2023-01-09 | Y |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-08-11 | 2022-11-11 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-16 | 2022-10-17 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-11 | 2022-10-11 | N |
| Provide appropriate foot care. | Health | 2022-08-16 | 2022-09-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-16 | 2022-09-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-08-16 | 2022-09-05 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Develop a communication plan. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-08-11 | 2022-09-05 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-08-16 | 2022-08-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-08-16 | 2022-08-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-16 | 2022-08-26 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2022-08-16 | 2022-08-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-16 | 2022-08-26 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-08-16 | 2022-08-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-16 | 2022-08-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-08-16 | 2022-08-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-08-16 | 2022-08-26 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-08-16 | 2022-08-26 | Y |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2022-08-16 | 2022-08-26 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-08-16 | 2022-08-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-15 | 2022-04-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-15 | 2022-04-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-25 | 2022-04-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-25 | 2022-04-16 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-27 | 2022-04-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-25 | 2022-03-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-25 | 2022-03-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-27 | 2022-02-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-17 | 2021-12-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-11-17 | 2021-12-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-17 | 2021-12-14 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-17 | 2021-12-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-11-17 | 2021-12-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-17 | 2021-12-14 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2021-10-14 | 2021-10-15 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-05-03 | 2021-05-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-03 | 2021-05-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-03 | 2021-05-25 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-05-03 | 2021-05-25 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-05-03 | 2021-05-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-05-03 | 2021-05-10 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-03 | 2021-05-10 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-05-03 | 2021-05-10 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-17 | 2021-04-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-02 | 2021-04-01 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-03-10 | 2020-04-17 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-03-10 | 2020-04-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-10 | 2020-04-15 | N |
| Post nurse staffing information every day. | Health | 2020-03-10 | 2020-04-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-03-10 | 2020-04-15 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-03-10 | 2020-04-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-03-11 | 2020-03-31 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-03-11 | 2020-03-30 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-03-11 | 2020-03-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-03-11 | 2020-03-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-03-11 | 2020-03-30 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-11 | 2020-03-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-03-11 | 2020-03-25 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-03-11 | 2020-03-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-11 | 2020-03-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-11 | 2020-03-25 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-03-11 | 2020-03-21 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2020-03-11 | 2020-03-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-11 | 2020-03-18 | N |
